King vs. Burwell Brings a Sigh of Relief, But Now it’s Back to Work!

We—along with many others—breathed a sigh of relief yesterday with the King vs. Burwell decision upholding one of the key pillars of the Affordable Care Act. We are relieved for the estimated 7.5 million people who received tax subsidies to buy insurance on Federally run state exchanges and will be able to keep their health coverage. We are also relieved for the administrators who have worked so hard to set up the infrastructure of an insurance market that serves most Americans. And, we need look no farther than John Roberts’ statement on the case to summarize the case: “this was not about sending insurance exchanges in to a death spiral.”

Insurance coverage is a first critical step if we want to achieve the real goal of health reform: better health for lower costs. Having more people with coverage means providers are being held accountable for quality processes and outcomes that payers require.

From an individual perspective, ACA-regulated coverage is important for everyone, and perhaps especially important among low-income populations. For all consumers, the benefits that qualified insurance plans must cover encourage people to seek preventive care before they get sick, and prevent financial ruin if an individual does fall ill. For low-income populations, our research shows that health coverage also seems to serve as a “gateway” to getting connected with mental health, substance use disorder services, and social services (e.g., housing assistance, SNAP benefits) that are just as necessary for achieving health outcomes at lower costs as having a primary care provider or access to affordable medications.

So, now back to the hard work many of us are doing to implement the other key pillars of the ACA: delivery system transformation and payment reform. Indeed, coverage is only the first step. Now we need to to seek ways to tie payments more to incentivizing and achieving the outcomes we want rather than paying for just the volume of services doctors and hospitals provide. We are busy working with health centers to change their care model and to design new ways of being paid. We are helping health systems to re-think and re-form their structures for accountability.

And hard work we must do. We must not forget that the U.S. is still in a policy crisis: we spend 18% of GDP on health care, and if we don’t make significant shifts to our trajectory, health care is projected to eclipse all non-Social Security, non-military Federal funding by 2037. I am all for health, but not at the expense of education. We also are going about our work realizing that change is hard. Becoming more accountable is hard for people and systems, especially when we’re talking about doing things differently and paying for things differently than in the past. Motivated partly by the imperative for change, I am also optimistic. There are lots of opportunities to think beyond the ways things have always been done. New managed care regulations are clarifying the flexibility of health plans to pay for services that will improve the quality of care in creative and evidence-based ways. At JSI, we are looking at novel integrations of housing and health, expanding the round-table of stakeholders in a community driving health outcomes and more efficient use of public funds.

With an insurance market death spiral averted, it’s back to work on accountable care.